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q : : SAN-JOAQUIN Environmental Health Department <br /> COUNT'Y <br /> �RL. r Greatness grows here <br /> New Well Information <br /> Pursuant to California Water Code, Section 13808, all new wells that do not meet the exemption <br /> criteria must submit the following required information, to the extent that can be reasonably known. <br /> The Environmental Health Department must collect this information before a new well permit is <br /> issued and must post the information on the Department's website for public information. <br /> WELL LOCATION AND OWNER INFORMATION <br /> Well Location Address: RIOC6City: MAIN <br /> Well Location APN: IA Q- 0 <br /> Well Latitude:-Y7. T6-j%2- Well Longitude: — �'LQ• Z Z <br /> Flood Plain Designation: Well Elevation: V <br /> Applicant Name: �`1 1 Y S V Applicant Title: <br /> Applicant Address 0-1,1 (� W�O�A, N. City: <br /> Applicant Phone: Applicant email: <br /> Property Owner Name: <br /> Property Owner Address: City: <br /> Property Owner Phone: Property Owner email: <br /> PROPOSED WELL INFORMATION <br /> Well Total Depth(ft):1 I Acres to be Served by Well: <br /> Use of Well: ❑ Domestic ation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑ Other: <br /> Depth of Corcoran Clay(ft): <br /> Proposed Well Capacity(gaVft): Estimated Pumping Rate(gal/min): <br /> Anticipated Pumping Schedule(gal/day): Estimated Annual Extraction Volume(acre-feet): N -1 1". <br /> Estimated Cumulative Extraction Volume before January 1,2020(acre-feet): <br /> EXISTING WELLS INWN <br /> Total Number of Existing Wells on Property: <br /> Please complete the information below for every well on property.Use extra paper if needed <br /> Well#1 Information <br /> Use of Well: Domestic ❑ Irrigation ❑Small Public Water Supply ❑ Municipal Public Water Supply ❑ Industrial ❑Stock <br /> ❑Other. <br /> Total Depth(ft): To: From: <br /> Casing Diameter(in): ❑Open Bottom or Screen Interval(ft): To: From: <br /> Pumping Rate(gpm): To: From: <br /> Annual Extraction Volume(acre-feet%6-M& DftEstimated ❑ Measured <br /> Specific Capacity(gaUmin/ft): <br /> Other Pumping Tests Performed: Test Result: <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />